Provider Demographics
NPI:1750686606
Name:MERCADO, ELLEN S (PA)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:S
Last Name:MERCADO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2723 POLK ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77003-4536
Mailing Address - Country:US
Mailing Address - Phone:281-565-0033
Mailing Address - Fax:
Practice Address - Street 1:4690 SWEETWATER BLVD
Practice Address - Street 2:ST #200
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-3467
Practice Address - Country:US
Practice Address - Phone:281-565-0033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07104363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX220482801Medicaid
TX845N06OtherBCBS
TX220482801Medicaid